MEDICATION COVERAGE POLICY - Health Plan of San Joaquin

MEDICATION COVERAGE POLICY

PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE

POLICY

THERAPEUTIC CLASS

LOB AFFECTED

Thyroid Disorders

Endocrine Disorders

Medi-Cal

P&T DATE:

REVIEW HISTORY

( MONTH / YEAR )

12/08/2020

12/19,12/18, 9/17, 12/16,

11/15

This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical

practice standards, and approved by the HPSJ Pharmacy and Therapeutic Advisory Committee.

? OVERVIEW

Treatment of hyperthyroidism and hypothyroidism is well-defined: methimazole and levothyroxine monotherapy are

the mainstays of treatment for hyperthyroidism and hypothyroidism, respectively.1,2 The purpose of this Thyroid

Disorders Coverage Policy is to review the coverage criteria of HPSJ¡¯s formulary anti-thyroid and thyroid agents (Table

1).

Table 1: Available Anti-Thyroid & Thyroid Medications (Current as of 09/2020)

Generic Name or

Brand Name

Available Strengths

Formulary

Limits

Average

Cost per Rx

ANTI-THYROID MEDICATIONS

Methimazole

Propylthiouracil

5, 10 mg tablets

50 mg tablet

Armour Thyroid

Levothyroxine sodium

Levoxyl

Liothyronine sodium

NP Thyroid

Synthroid

Tirosint

WP Thyroid

15, 30, 60, 90, 120, 180, 240, 300 mg tablets

25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg tablets

25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200 mcg tablets

5, 25, 50 mcg tablets

48.75, 65, 81.25, 97.5, 113.75, 130, 146.25, 162.5, 195, 260, 325 mg

tablets

15, 30, 60, 90,120 mg tablets

25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg tablets

13, 25, 50, 75, 88, 100, 112, 125, 137, 150 mcg capsules

16.25, 32.5, 48.75, 65, 81.25, 97.5, 113.75, 130 mg tablets

Thyrogen

1.1 mg vial

-

$4.93

$33.30

NF

-

$39.52

$10.60

$32.58

$27.19

NF

$10.98

NF

NF

NF

$23.04

$43.01

$140.95

--

THYROID MEDICATIONS

Nature-Throid

THYROID FUNCTION DIAGNOSTIC AGENT

PA ; SP

$3,417.05

Bolded items = Brand name drug cost/utilization; PA = Prior Authorization Required; NF = Non-formulary; SP = Restricted to Specialty Pharmacy

? EVALUATION CRITERIA FOR APPROVAL/EXCEPTION CONSIDERATION

Below are the coverage criteria and required information for each agent. These coverage criteria have been reviewed &

approved by the HPSJ Pharmacy & Therapeutics (P&T) Advisory Committee. For conditions not covered under this

Coverage Policy, HPSJ will make the determination based on Medical Necessity as described in HPSJ Medical Review

Guidelines (UM06).

Anti-Thyroid Agents

Methimazole, Propylthiouracil

? Coverage Criteria: None

? Limits: None

? Required Information for Approval: N/A

? Other Notes: None

Thyroid Agents

Armour Thyroid, Levothyroxine sodium, Liothyronine sodium, NP Thyroid, Synthroid, Tirosint

Armour Thyroid, Levothyroxine sodium, Liothyronine sodium, NP Thyroid

? Coverage Criteria: None

? Limits: None

Coverage Policy ¨C Endocrine Disorders ¨C Thyroid Disorders

Page 1

? Required Information for Approval: N/A

? Other Notes: None

? Non-Formulary: Brand name Synthroid, Tirosint

Thyroid Agents

Thyrotropin alfa (Thyrogen)

? Coverage Criteria: Approval is determined by medical necessity criteria.

? Limits: None

? Required Information for Approval: N/A

? Other Notes: Medication is to be dispensed by HPSJ¡¯s designated Specialty Pharmacy.

? CLINICAL JUSTIFICATION

Methimazole is recommended for the treatment of all patients with Graves¡¯ Disease (except during the first trimester of

pregnancy), in the treatment of thyroid storm, and in patients who refuse radioactive iodine therapy or surgery. 1

During the first trimester of pregnancy, propylthiouracil is preferred because it does not cross the placenta as readily,

whereas methimazole has been associated with rare birth defects.3 Levothyroxine monotherapy is the current

standard of care for treating hypothyroidism. Levothyroxine (synthetic T4) is preferred over T3 agents (desiccated

thyroid extracts and liothyronine) due to its long half-life and better gastrointestinal absorption.2

? REFERENCES

1.

2.

3.

Bahn RS, Burch HB, Cooper DS et al. Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the

American Thyroid Association and the American Association of Clinical Endocrinologists. Endocr Pract. 2011;17(3):456-520.

Garber JR, Cobin RH, Gharib H et al. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American

Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988¨C1028.

Thyroid disease in pregnancy. Practice Bulletin No. 148. American College of Obstetricians and Gynecologists. Obstet Gynecol.

2015;125:996¨C1005.

? REVIEW & EDIT HISTORY

Document Changes

Creation of Policy

Update to Policy

Update to Policy

Update to Policy

Reference

HPSJ Coverage Policy ¨C Endocrine Disorders ¨C Thyroid

Disorders 2015-11.docx

HPSJ Coverage Policy - Endocrine Disorders - Thyroid

Disorders 2016-12.docx

HPSJ Coverage Policy - Endocrine Disorders - Thyroid

Disorders 2017-09.docx

HPSJ Coverage Policy ¨C Endocrine ¨C Thyroid Disorders

2018-12.docx

Thyroid Disorders

Date

11/2015

P&T Chairman

Johnathan Yeh, PharmD

12/2016

Johnathan Yeh, PharmD

9/2017

Johnathan Yeh, PharmD

Matthew Garrett,

PharmD

Review Policy

12/2019

Matthew Garrett,

PharmD

Review Policy

Thyroid Disorders

12/2020

Matthew Garrett,

PharmD

Note: All changes are approved by the HPSJ P&T Committee before incorporation into the utilization policy

Coverage Policy ¨C Endocrine Disorders ¨C Thyroid Disorders

12/2018

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